Basic Information
| Provider Information | |||||||||
| NPI: | 1932241197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRACY | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 REV NAZARENO PROPERZI WAY | ||||||||
| Address2: | |||||||||
| City: | SOMERVILLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021433204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176663527 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 39 INDUSTRIAL PARK RD # A | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023604868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088301444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 5984 | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.